The Strain Index (SI) and Threshold Limit Value (TLV) for Hand Activity Level (HAL): risk of carpal tunnel syndrome (CTS) in a prospective cohort.

A cohort of 536 workers was enrolled from 10 diverse manufacturing facilities and was followed monthly for six years. Job physical exposures were individually measured. Worker demographics, medical history, psychosocial factors, current musculoskeletal disorders (MSDs) and nerve conduction studies (NCS) were obtained. Point and lifetime prevalence of carpal tunnel syndrome (CTS) at baseline (symptoms + abnormal NCS) were 10.3% and 19.8%. During follow-up, there were 35 new CTS cases (left, right or both hands). Factors predicting development of CTS included: job physical exposure (American conference of governmental industrial hygienists Threshold Limit Value (ACGIH TLV) for Hand Activity Level (HAL) and the Strain Index (SI)), age, BMI, other MSDs, inflammatory arthritis, gardening outside of work and feelings of depression. In the adjusted models, the TLV for HAL and the SI were both significant per unit increase in exposure with hazard ratios (HR) increasing up to a maximum of 5.4 (p = 0.05) and 5.3 (p = 0.03), respectively; however, similar to other reports, both suggested lower risk at higher exposures. Data suggest that the TLV for HAL and the SI are useful metrics for estimating exposure to biomechanical stressors. PRACTITIONER SUMMARY: This study was conducted to determine how well the TLV for HAL and the SI predict risk of CTS using a prospective cohort design with survival analysis. Both the TLV for HAL and the SI were found to predict risk of CTS when adjusted for relevant covariates.

Use of fluorescence in situ hybridization to clarify a complex chromosomal rearrangement in a child with multiple congenital anomalies.

A child with multiple congenital anomalies was referred for cytogenetic evaluation. G-banded analysis showed a complex chromosome rearrangement involving 6 different chromosomes and 10 breakpoints. Fluorescence in situ hybridization (FISH) using whole chromosome painting probes and repetitive sequence probes was performed. In most cases the painting probes alone helped to clarify the G-banded results. However, in one instance, where the terminal band of the long arm of chromosome 1 was involved, the use of a telomeric probe was essential in defining the rearrangement.

Segregation of a paternal insertional translocation results in partial 4q monosomy or 4q trisomy in two siblings.

A genetics evaluation was requested for a 6-week-old infant with multiple congenital malformations including mild craniofacial anomalies, truncal hypotonia, hypospadias, and a ventriculoseptal defect. Blood obtained for chromosome analysis revealed an abnormal chromosome 4. Paternal chromosome analysis showed a 46,XY, inv ins (3;4)(p21.32;q25q21.2), inv(4)(p15.3q21.2) karyotype. Therefore, the proband's chromosome 4 was the unbalanced product of this insertional translocation from the father resulting in partial monosomy 4q. Additionally, the derivative 4 had a pericentric inversion which was also seen in the father's chromosome 4. During genetic counseling, the proband's 2-year-old brother was evaluated. He was not felt to be abnormal in appearance, but was described as having impulsive behavior. Chromosome analysis on this child revealed 46,XY,der(3)inv ins(3;4)(p21.32;q25q21.2)pat. This karyotype results in partial trisomy 4q. FISH using two-color "painting" probes for chromosomes 3 and 4 confirmed the G-banded interpretation in this family. The segregation seen in this family resulted in both reciprocal products being observed in the two children, with partial 4q monosomy showing multiple congenital anomalies, and partial 4q trisomy showing very few phenotypic abnormalities.

Hazardous materials readiness of United States level 1 trauma centers.

Injuries caused by hazardous materials (hazmat) accidents are common in the United States, and emergency departments should be capable of decontaminating these patients. There are, however, no national studies that assess emergency department preparedness. The purpose of this survey was to assess the hazmat readiness of US Level 1 trauma centers (TCs). All 1996 Hospital Blue Book TCs (256) were queried by anonymous survey; 61% (156) responded to the survey. The TCs treated 43,046 +/- 28,455 patients (median, 40,500; range, 600 to 220,000); 15 +/- 29 (median, 6; range, 0 to 200) were hazmat-contaminated. Only 6% acknowledged having all necessary equipment required for safe decontamination. Many (83%) had hazmat response plans, but few (30%) of these plans were complete. Approximately 36% of the staff had received training. Thirteen staff required medical attention themselves after rendering care to a contaminated patient. Only 58% of the TCs performed a single drill. The preparedness of US Level 1 TCs to safely decontaminate hazmat patients seems to be inadequate.

Effectiveness of Waddell's nonorganic signs in predicting a delayed return to regular work in patients experiencing acute occupational low back pain.

STUDY DESIGN: Consecutive case series. OBJECTIVE: To determine whether the presence of Waddell's nonorganic signs in occupational, acute low back pain patients predicts a longer time before return to unrestricted regular work. SUMMARY OF BACKGROUND DATA: Waddell's nonorganic signs identify patients with chronic low back pain with a poor prognosis; however, they have not been used as an outcome predictor in patients with occupational, acute low back pain. METHODS: Standardized histories and physical examinations, including Waddell's signs were recorded at the first clinic visit (n = 143) by a single physician who was not blinded to the study's goals or methods. Those with chronic low back pain or complicating medical conditions (n = 88) were excluded. Data from patients exhibiting the nonorganic signs were compared with those from patients without the signs for time to return to regular work without restrictions and medical resource use. RESULTS: Fifty-five patients with acute work-related low back pain were included. One or more of the nonorganic signs were seen in 14 patients (25.5%) at the first appointment. The most common signs were simulated axial loading (78.6%) and simulated rotation (71.4%). Those with any nonorganic sign required a median 58.5 days to return to regular work compared with 15.0 days for those without (P < 0.0001). Patients exhibiting any nonorganic sign compared with those without used more physical therapy (50.0% vs. 12.2%; P < 0.01) and lumbar computed axial tomography (21.4% vs. 0.0%; P = 0.01). CONCLUSIONS: Patients with acute, occupational low back pain exhibiting Waddell's nonorganic signs had a four times lengthier time for return to unrestricted, regular work and a greater use of physical therapy and lumbar computed tomographic scans.

Cellulitis incidence in a defined population.

A population-based insurance claims database was used to examine cellulitis incidence, anatomical sites of infection, complicating diagnoses, source of health service, and recurrence rates. Insurance claim files were searched for cellulitis ICD-9-CM codes 681.0-682.9. Complications of cellulitis including erysipelas, lymphadenitis, lymphangitis, and necrotizing fasciitis were also identified by ICD-9-CM codes. We found a cellulitis incidence rate of 24.6/1000 person-years, with a higher incidence among males and individuals aged 45-64 years. The most common site of infection was the lower extremity (39.9%). The majority of patients were seen in an outpatient setting (73.8%), and most (82.0%) had only one episode of cellulitis during the 5-year period studied. There was a very low incidence of cellulitis complications, including necrotizing fasciitis. Cellulitis is fairly common, usually treated in outpatient settings, and is infrequently complicated by erysipelas, lymphadenitis, lymphangitis, or necrotizing fasciitis.

Occupational medicine training program surveys.

Although the quantity of Occupational Medicine (OM) residents in training programs has risen in the past 15 years, there remains a significant shortage of OM physicians in the United States. A survey of OM residency program directors and residents and fellows (trainees) was accomplished to answer questions relevant to recruiting and supplying OM trained physicians. Twenty-six of 29 program directors (89.7%) replied. One hundred forty-three of 174 (82.2%) trainees responded. Fifty percent of responding program directors were satisfied with the current quantity of program applicants. Medical students were provided a median of 3 hours (range, 0 to 20 hours; mean, 5.35 hours) of formal OM teaching by the responding programs. Almost half of trainees, 68 (48.6%), did not receive formal OM instruction in medical school. An average of 5.4 +/- 13.3 hours of OM was taught to OM trainees in medical school. Disproportionate numbers of trainees were taught OM as fourth-year medical students and in other residencies. Reasons for pursuing OM training were diverse and often related to postgraduate clinical experience with OM. Only a total of 84 primary care residents (0.32%) rotate through the OM residency programs in an average year. We conclude that an insufficient quantity of qualified applicants, combined with limited exposure to OM in medical schools and low levels of contact with residents in primary care programs, will continue to hinder efforts to reduce the shortage of OM residents and physicians. Further training specifically targeting the fourth year of medical school and the primary care residencies may have the most impact on recruitment.

Medication reporting in the workplace.

Impairment from medication use in hazardous work environments has not been well studied. We analyzed incident events in an explosive manufacturing facility using a retrospective case control study to determine whether medication use was related to safety incidents. Medication use between the incident group and the controls was not significantly different. However, 23% of the incident group had been employed by the facility for less than 1 year compared with 2% of controls. Only 19% of restricted medication use was self-reported. In this study, being employed less than 1 year was a greater predictor of safety incidents than was medication use, and self-reporting did not reflect actual medication use. We conclude that medication use is not directly related to safety events and that a self-reporting program is difficult to justify in the corporate setting.

DOT examinations: practical aspects and regulatory review.

Most certification examinations of commercial drivers are simple, and relatively few drivers are disqualified. If these examinations are not done properly, however, the public can be exposed to potentially unqualified drivers. Should an accident occur, the physician who examined the driver may be found liable. In performing driver certification examinations, the physician's primary responsibility is to the public. The Federal Motor Carriers Safety Regulations and supporting documents provide guidelines for the conditions that may be disqualifying and the conditions that may allow only temporary certification until better medical control is achieved. Some medical diagnoses, such as insulin-requiring diabetes mellitus, are automatically disqualifying, no matter how well the disease is controlled. Other conditions may require documented clearance from a specialist before certification is granted.

The effect of age at smoking initiation on lung cancer risk.

It has been assumed that a younger age at initiation of cigarette smoking is associated with an increased risk of lung cancer, but previous studies have not adjusted for two strong risk factors, the amount smoked and duration smoked. We used data from a population-based case-control study with 282 histologically confirmed lung cancer cases matched to 3,282 random controls to determine whether age at initiation of smoking plays an independent role in the occurrence of lung cancer. After controlling for age, sex, and amount of tobacco exposure, men who began to smoke before age 20 had a substantially higher risk of developing lung cancer [odds ratio (OR) = 12.7; 95% confidence interval (CI) = 6.39-25.2] compared with men who began smoking at age 20 or older (OR = 6.03; 95% CI = 2.82-12.9). For women, the heavy increase in risk continued until age 25 (OR = 9.97; 95% CI = 4.68-21.2) compared with women who began smoking at age 26 or older (OR = 2.58; 95% CI = 0.53-12.4). There was no predisposition toward a specific histologic type of lung cancer. In this study, up to 52.4% of lung cancer cases in men and up to 73.0% of lung cancer cases in women could be attributed to this effect of early age of first smoking.